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Based on record review and interview, it was determined the facility failed to ensure the facility had a policy and procedure for tracking on-duty staff and sheltered patients in the event of an emergency per the requirements for 42 CFR 483.73. The deficiency had the potential to affect four (4) of four (4) smoke compartments, residents, staff and visitors. The facility is certified for twenty-five (25) beds with a census of thirteen (13) on the day of the survey.

The findings include:

Record review of the Emergency Preparedness Plan on 02/27/18 at 1:48 PM with the Maintenance Director revealed the facility did not have a procedure in place to track on-duty staff and sheltered patients in the event of an emergency.

Interview on 02/27/18 at 1:49 PM with the Maintenance Director revealed he was not aware of the requirement for tracking on-duty staff and sheltered patients in the event of an emergency.

The census of thirteen (13) was verified by the CEO on 02/27/18. The findings were acknowledged by the CEO and verified by the Maintenance Director at the exit interview on 02/27/18.


Reference: 42 CFR 483.73
Emergency Preparedness.

(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:]

(2) A system to track the location of on-duty staff and sheltered patients in the [facility ' s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location.

*[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF ' s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF ' s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location.

*[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures.
(ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance.
(v) A system to track the location of hospice employees ' on-duty and sheltered patients in the hospice ' s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location.

*[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

*[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.

Based on record review and interview, it was determined the facility failed to ensure the facility had a policy and procedure for volunteers in the event of an emergency per the requirements for 42 CFR 483.73. The deficiency had the potential to affect four (4) of four (4) smoke compartments, residents, staff and visitors. The facility is certified for twenty-five (25) beds with a census of thirteen (13) on the day of the survey.

The findings include:

Record review of the Emergency Preparedness Plan on 02/27/18 at 1:48 PM with the Maintenance Director revealed the facility did not have a procedure in place for volunteers in the event of an emergency.

Interview on 02/27/18 at 1:49 PM with the Maintenance Director revealed he was not aware of the requirement for a procedure for volunteers in the event of an emergency.

The census of thirteen (13) was verified by the CEO on 02/27/18. The findings were acknowledged by the CEO and verified by the Maintenance Director at the exit interview on 02/27/18.


Reference: 42 CFR 483.73
Emergency Preparedness

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:]

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

Based on record review and interview, it was determined the facility failed to ensure the cooking appliances were in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, residents, staff and visitors. The facility is certified for twenty-five (25) beds with a census of thirteen (13) on the day of the survey.

The findings include:

Record review on 02/27/18 at 12:52 PM with the Maintenance Director revealed the last time the Kitchen Hood had been cleaned was on 07/06/17.

Interview on 02/28/18 at 12:53 PM with the Maintenance Director revealed he was aware of the requirements for the Kitchen Hood to be cleaned every six (6) month. However, he was not aware the Kitchen Hood had not been cleaned since 07/06/17.


The census of thirteen (13) was verified by the CEO on 02/28/18. The findings were acknowledged by the CEO and verified by the Maintenance Director at the exit interview on 02/28/18.

Reference: NFPA 101 (2012 edition)

9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.